Professor of Health Policy and Public Service

John Billings, Professor of Health Policy and Public Service. He is principal investigator on numerous projects to assess the performance of the safety net for vulnerable populations and to understand the nature and extent of barriers to optimal health for vulnerable populations. Much of his work has involved analysis of patterns of hospital admission and emergency room visits as a mechanism to evaluate access barriers to outpatient care and to assess the performance of the ambulatory care delivery system. He has also examined the characteristics of high cost Medicaid patients in to help in designing interventions to improve care and outcomes for these patients. Parallel work in the United Kingdom has involved creating an algorithm for the National Health Service to identify patients at risk of future hospital admissions and designing interventions to improve care for these high risk patients. As a founding member of the Foundation for Informed Decision Making, Professor Billings is helping to provide patients with a clearer mechanism for understanding and making informed decisions about a variety of available treatments. Professor Billings received his J.D. from the University of California (Berkeley).

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.

2013

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients’ total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.

Objectives To develop an algorithm for identifying inpatients at high risk of re-admission to a National Health Service (NHS) hospital in England within 30 days of discharge using information that can either be obtained from hospital information systems or from the patient and their notes.

Participants The NHS patients were admitted to hospital between April 2008 and March 2009 (10% sample of all admissions, n=576 868).

Main outcome measures Area under the receiver operating characteristic curve for the algorithm, together with its positive predictive value and sensitivity for a range of risk score thresholds.

Results The algorithm produces a ‘risk score’ ranging (0–1) for each admitted patient, and the percentage of patients with a re-admission within 30 days and the mean re-admission costs of all patients are provided for 20 risk bands. At a risk score threshold of 0.5, the positive predictive value (ie, percentage of inpatients identified as high risk who were subsequently re-admitted within 30 days) was 59.2% (95% CI 58.0% to 60.5%); representing 5.4% (95% CI 5.2% to 5.6%) of all inpatients who would be re-admitted within 30 days (sensitivity). The area under the receiver operating characteristic curve was 0.70 (95% CI 0.69 to 0.70).

Conclusions We have developed a method of identifying inpatients at high risk of unplanned re-admission to NHS hospitals within 30 days of discharge. Though the models had a low sensitivity, we show how to identify subgroups of patients that contain a high proportion of patients who will be re-admitted within 30 days. Additional work is necessary to validate the model in practice.

Objective: To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.

Design: Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat.

Setting: 179 general practices in three areas in England.

Participants: 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009.

Interventions: Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients’ diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.

Results: Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P<0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P=0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference −0.64 days, −1.14 to −0.10, P=0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group.

Conclusions: Telehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect.

Study Design
This study was commissioned after the interventions had been in place for several years. We developed a method based on retrospective analysis of person-level data comparing health care use of participants with that of prognostically matched controls.

Data Collection/Extraction Methods
Individuals were linked to administrative datasets through a trusted intermediary and a unique patient identifier.

Principal Findings
Participants who received the intermediate care intervention showed higher rates of unscheduled hospital admission than matched controls, whereas recipients of the integrated care team intervention showed no difference. Both intervention groups showed higher rates of mortality than did their matched controls.

Conclusions
These are potentially powerful techniques for assessing impacts on hospital activity. Neither intervention reduced admission rates. Although our analysis of hospital utilization controlled for a wide range of observable characteristics, the difference in mortality rates suggests that some residual confounding is likely. Evaluation is constrained when performed retrospectively, and careful interpretation is needed.

Patients with frequent hospitalizations generate a disproportionate share of hospital visits and costs. Accurate determination of patients who might benefit from interventions is challenging: most patients with frequent admissions in 1 year would not continue to have them in the next. Our objective was to employ a validated regression algorithm to case-find Medicaid patients at high-risk for hospitalization in the next 12 months and identify intervention-amenable characteristics to reduce hospitalization risk. We obtained encounter data for 36,457 Medicaid patients with any visit to an urban public hospital from 2001 to 2006 and generated an algorithm-based score for hospitalization risk in the subsequent 12 months for each patient (0 = lowest, 100 = highest). To determine medical and social contributors to the current admission, we conducted in-depth interviews with high-risk hospitalized patients (scores >50) and analyzed associated Medicaid claims data. An algorithm-based risk score >50 was attained in 2,618 (7.2%) patients. The algorithm’s positive predictive value was equal to 0.67. During the study period, 139 high-risk patients were admitted: 60 met inclusion criteria and 50 were interviewed. Fifty-six percent cited the Emergency Department as their usual source of care or had none. Sixty-eight percent had >1 chronic medical conditions, and 42% were admitted for conditions related to substance use. Sixty percent were homeless or precariously housed. Mean Medicaid expenditures for the interviewed patients were $39,188 and $84,040 per patient for the years immediately prior to and following study participation, respectively. Findings including high rates of substance use, homelessness, social isolation, and lack of a medical home will inform the design of interventions to improve community-based care and reduce hospitalizations and associated costs.

2007

This paper offers some reflections on the grant-making process from a former foundation executive. Some of the opportunities, challenges, and pitfalls inherent in the foundation world are described, and one approach to grant making, the "call for proposals," is examined as an example of the need for greater attention to and investment in the science of grant making itself, to maximize the potential return from philanthropy.

This study seeks to understand the perspective of Black and Hispanic/Latino residents of the South Bronx, New York, on the causes of persistent racial and ethnic disparities in health outcomes. In particular, it focuses on how people who live in this community perceive and interact with the health care system. Findings from 9 focus groups with 110 participants revealed a deep and pervasive distrust of the health care system and a sense of being disrespected, exacerbated by difficulties that patients experience in communicating with their providers. The paper suggests how health care institutions might respond to these perceptions.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

2004

High cost patients account for a large share of Medicaid costs (20 percent of patients account for 70 to 80 percent of expenditures). This study analyzes expenditures, patterns of utilization, and diagnostic characteristics of the most costly of these patients.

The usefulness of patient decision aids (PtDAs) is well documented, yet they are not in widespread use. Barriers include assuring balance and fairness (auspices matter), the cost of producing and maintaining them, and getting them into the hands of patients at the right time. The Foundation for Informed Medical Decision Making and its for-profit partner, Health Dialog, have developed a creative business model that helps overcome these barriers and has greatly expanded the reach of decision aids.

Although many community-based initiatives employ community residents to undertake door-to-door surveys as a form of community mobilization or for purposes of needs assessment or evaluation, very little has been published on the strengths and weaknesses of this approach. This article discusses our experience in undertaking such a survey in collaboration with a coalition of community-based organizations (CBOs) in the South Bronx, New York. Although resource constraints limited the already-strained capacity of the CBOs to provide supervision, the CBOs and community surveyors helped us gain access to neighborhood buildings and to individuals who might otherwise have been inaccessible. The survey process also contributed to the coalition's community outreach efforts and helped to link the CBO leadership and staff more closely to the coalition and its mission. Many of the surveyors enhanced their knowledge and skills in ways that have since benefited them or the coalition directly. The participating CBOs continue to be deeply engaged in the coalition's work, and many of the surveyors are active as community health advocates and have taken leadership roles within the coalition.

2003

One of the challenges in monitoring the Nation's health care safety net is that safety net services are provided in a myriad of different configurations, largely at the local level. Book 1. Data for Metropolitan Areas presents data from 90 metropolitan areas in 30 States and the District of Columbia, including 354 counties and 171 cities. The data describe the health care safety net where 80 percent of Americans with family incomes below the Federal poverty line live.

2000

It is becoming increasingly apparent that over the next several years the majority of Medicaid patients in many states will become enrolled in managed care plans, some voluntarily, but most as the result of mandatory initiatives. An important issue related to this development is the extent to which this movement to managed care is accompanied by serious selection effects, either across the board during the phase in or among individual plans or plan types with full-scale implementation. This paper examines selection effects in New York City between 1993 and 1997 during the voluntary enrollment period prior to implementation of mandatory enrollment pursuant to a Section 1115 waiver. No substantial selection bias was documented between patients entering managed care and those remaining in the fee-for-service system among the largest rate groups, although some selection effect was found among plans and plan types (with investor-owned plans enrolling patients with lower prior utilization and expenses).